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Singh A, von Vogelsang AC, Tatter C, El-Hajj VG, Fletcher-Sandersjöö A, Cewe P, Nilsson G, Blixt S, Gerdhem P, Edström E, Elmi-Terander A. Dysphagia, health-related quality of life, and return to work after occipitocervical fixation. Acta Neurochir (Wien) 2024; 166:90. [PMID: 38374453 PMCID: PMC10876741 DOI: 10.1007/s00701-024-05991-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/26/2023] [Indexed: 02/21/2024]
Abstract
PURPOSE The purpose of this study was to evaluate patient-reported outcome measures (PROMS) on dysphagia, health-related quality of life (HRQoL) and return to work after occipitocervical fixation (OCF). Postoperative radiographic measurements were evaluated to identify possible predictors of dysphagia. METHODS All individuals (≥ 18 years) who underwent an OCF at the study center or were registered in the Swedish spine registry (Swespine) between 2005 and 2019, and were still alive when the study was conducted, were eligible for inclusion. There was no overlap between the cohorts. Prospectively collected data on dysphagia (Dysphagia Short Questionnaire DSQ), HRQoL (EQ5D-3L) and return to work were used. Radiological and baseline patient data were retrospectively collected. In addition, HRQoL data of a matched sample of individuals was elicited from the Stockholm Public Health Survey 2006. RESULTS In total, 54 individuals were included. At long-term follow-up, 26 individuals (51%) had no dysphagia, and 25 (49%) reported some degree of dysphagia: 11 (22%) had mild dysphagia, and 14 (27%) had moderate to severe dysphagia. On a group level, the OCF sample scored significantly lower EQVAS and EQ-5Dindex values compared to the general population (60.0 vs. 80.0, p = 0.016; 0.43 vs. 0.80, p < 0.001). Individuals working preoperatively returned to work after surgery. Of those responding, 88% stated that they would undergo the OCF operation if it was offered today. No predictors of dysphagia based on radiographic measurements were identified. CONCLUSION Occipitocervical fixation results in a high frequency of long-term dysphagia. The HRQoL of OCF patients is significantly reduced compared to matched controls. However, most patients are satisfied with their surgery. No radiographic predictors of long-term dysphagia could be identified. Future prospective and systematic studies with larger samples and more objective outcome measures are needed to elucidate the causes of dysphagia in OCF.
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Affiliation(s)
- Aman Singh
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | | | - Charles Tatter
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | | | | | - Paulina Cewe
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Gunnar Nilsson
- Capio Spine Center Stockholm, Löwenströmska Hospital, Upplands-Väsby, Sweden
| | - Simon Blixt
- Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Paul Gerdhem
- Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Orthopedics and Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Capio Spine Center Stockholm, Löwenströmska Hospital, Upplands-Väsby, Sweden
- Department of Medical Sciences, Örebro University, Örebro, Sweden
| | - Adrian Elmi-Terander
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
- Capio Spine Center Stockholm, Löwenströmska Hospital, Upplands-Väsby, Sweden.
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
- Department of Medical Sciences, Örebro University, Örebro, Sweden.
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Luan H, Liu X, Liu K, Song J, Peng C, Sheng W, Deng Q. Development and Validation of a Predictive Model to Evaluate the Risk of Dysphagia Following Anterior Cervical Discectomy and Fusion. Global Spine J 2023:21925682231204160. [PMID: 37832034 DOI: 10.1177/21925682231204160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2023] Open
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE To investigate the potential risk factors of dysphagia after anterior cervical discectomy and fusion (ACDF) and to establish and validate a prediction model. METHODS The clinical data of 252 patients who underwent anterior cervical discectomy and fusion in our hospital from January 2018 to October 2020 were retrospectively analyzed and divided into the dysphagia group and the non-dysphagia group according to whether dysphagia occurred after surgery. Age, gender, body mass index, smoking and drinking history, hypertension history, diabetes history, disease duration, placement of Hemovac negative pressure drain, number of segments involved in surgery, whether C4-5/C5-6 segment surgery, incision length, incision position, level of preoperative EAT-10 score, whether preoperative tracheal exercise, and changes in cervical curvature before and after surgery were recorded in both groups. Risk factors for postoperative dysphagia were identified and nomogram prediction models were developed. RESULTS A total of 252 patients were included in the study, 115 of whom presented with dysphagia within 1 week after anterior cervical fusion. The results of multivariate logistic regression analysis indicated that male gender (OR = .045, 95% CI .223-.889) and whether preoperative tracheal exercise (OR = .260, 95% CI .107-.633) were independent risk factors associated with reduced incidence of postoperative dysphagia. CONCLUSION The incidence of dysphagia symptoms after anterior cervical decompression and fusion gradually decreased with the extension of follow-up time, and preoperative tracheal exercise and shortening the operation time may help to reduce the occurrence of postoperative dysphagia.
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Affiliation(s)
- Haopeng Luan
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaokang Liu
- Department of Orthopaedics, Yiwu Central Hospital, Yiwu, China
| | - Kai Liu
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Jiazhao Song
- Department of Graduate School, Hebei North University, Zhangjiakou, China
| | - Cong Peng
- Department of Trauma and Microreconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Weibin Sheng
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Qiang Deng
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Molfenter SM, Amin MR, Balou M, Herzberg EG, Frempong-Boadu A. A scoping review of the methods used to capture dysphagia after anterior cervical discectomy and fusion: the need for a paradigm shift. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:969-976. [PMID: 36625955 PMCID: PMC10805127 DOI: 10.1007/s00586-022-07515-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/02/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Dysphagia is the most commonly reported complication of annterior cervical discectomy and fusion (ACDF) surgery. However, the incidence of dysphagia post-ACDF varies widely-partly attributable to differing outcome measures used to capture dysphagia. Our objective was to conduct a scoping review of the literature to quantify which dysphagia outcome measures have been employed post-ACDF and examine trends by study design, year, and location. METHODS After removing duplicates, 2396 abstracts were screened for inclusion. A total of 480 studies were eligible for full-text review. After applying exclusion criteria, data was extracted from 280 studies. We extracted the dysphagia outcome measure(s), study design (prospective vs retrospective), year, and location (country). Approximately 10% of studies were repeated for intra-rater agreement. RESULTS In total, 317 dysphagia outcome measures were reported in 280 studies (primarily retrospective-63%). The largest proportion of outcome measures were categorized as "unvalidated patient-reported outcome measures" (46%), largely driven by use of the popular Bazaz scale. The next most common categories were "insufficient detail" and "validated patient-reported outcome measures" (both 16%) followed by "chart review/database" (13%) and instrumental assessment (7%). Studies examining dysphagia post-ACDF steadily increased over the years and the use of validated measures increased in the past 10 years. CONCLUSIONS This scoping review of the literature highlights that nearly half of the ACDF dysphagia literature relies on unvalidated patient-reported outcome measures. The current understanding of the mechanism, timeline, and presentation of dysphagia post-ACDF are likely limited due to the metrics that are most commonly reported in the literature.
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Affiliation(s)
- Sonja M Molfenter
- Department of Communicative Sciences and Disorders, NYU Steinhardt, 665 Broadway, Room 622, New York, NY, 10012, USA.
- Rusk Rehabilitation, NYU Langone Health, New York, NY, USA.
| | - Milan R Amin
- Department of Otolaryngology, Head & Neck Surgery, NYU Langone Health, New York, NY, USA
| | - Matina Balou
- Department of Otolaryngology, Head & Neck Surgery, NYU Langone Health, New York, NY, USA
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Tatter C, El-Hajj VG, Fletcher-Sandersjöö A, Edström E, Elmi-Terander A. Radiographic measurements for the prediction of dysphagia after occipitocervical fusion: a systematic review. Acta Neurochir (Wien) 2023; 165:1161-1170. [PMID: 36781463 PMCID: PMC10140007 DOI: 10.1007/s00701-023-05509-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 01/19/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Occipitocervical fusion (OCF) is a procedure performed for multiple upper cervical pathologies. A common postprocedural complication of OCF is dysphagia, which has been linked to the narrowing of the pharyngeal space due to fixation in a hyper-flexed angle. Postoperative dysphagia is linked to reduced quality of life, prolonged hospital stay, aspiration pneumonia, and increased mortality. This has led to investigations of the association between sagittal radiographic angles and dysphagia following OCF. METHODS A systematic review of the literature was performed to explore the current evidence regarding cervical sagittal radiographic measurements and dysphagia following OCF. A search strategy was carried out using the PubMed, Embase, and Web of Science databases from their dates of inception until August 2022. Only original English-language studies were considered. Moreover, studies had to include the correlation between dysphagia and at least one radiographic measurement in the sagittal plane. RESULTS The search and subsequent selection process yielded eight studies that were included in the final review, totaling 329 patients in whom dysphagia had been assessed and graded. The dysphagia score by Bazaz et al. (Spine 27, 22:2453-2458, 2002) was used most often. The pooled incidence of dysphagia, in the early postoperative period, was estimated at 26.4%. At long-term follow-up (range: 17-72 months), about one-third of patients experienced resolution of symptoms, which resulted in a long-term post-OCF dysphagia incidence of 16.5%. Across the studies included, six different radiographic parameters were used to derive several measures which were repeatedly and significantly associated with the occurrence of dysphagia. CONCLUSIONS The high incidence of postoperative dysphagia following OCF warrants close monitoring of patients, especially in the short-term postoperative period. These patients may be assessed through standardized tools where the one by Bazaz et al. was the most commonly used. Moreover, there are several radiographic measurements that can be used to predict the occurrence of dysphagia. These findings may serve as a basis for strategies to prevent the occurrence of dysphagia after OCF.
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Affiliation(s)
- Charles Tatter
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Capio Spine Center Stockholm, Löwenströmska Hospital, Upplands Väsby, Sweden
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Nachiappan M, Gadiyaram S. Bone Graft Erosion into Hypopharynx Presenting with Stridor: Rare Late Complication Following Cervical Spine Surgery. Indian J Otolaryngol Head Neck Surg 2022; 74:5105-5107. [PMID: 36742504 PMCID: PMC9895719 DOI: 10.1007/s12070-021-02850-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/02/2021] [Indexed: 02/07/2023] Open
Abstract
Cervical bone graft erosion occurs in about 2% of patients as a late complication following cervical spine fusion surgery. The usual presentation in such patients is dysphagia. Stridor is a very rare late complication of such bone erosions. We report a 66-year-old gentleman who presented with stridor, describe the management thereof.
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Affiliation(s)
- Murugappan Nachiappan
- Department of Surgical Gastroenterology and MIS, Sahasra Hospital, New No. 30, 39th Cross, Jayanagar 8th Block, Bangalore, 560082 India
| | - Srikanth Gadiyaram
- Department of Surgical Gastroenterology and MIS, Sahasra Hospital, New No. 30, 39th Cross, Jayanagar 8th Block, Bangalore, 560082 India
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Krafft PR, Peto I, Flores-Milan G, Reeves C, Klein S, Alikhani P, Tran ND. Kyphoplasty of C2 Pathological Fractures Using an Anterior Midline Approach and Steerable Osteotome: Technical Note and Case Series. Oper Neurosurg (Hagerstown) 2022; 23:457-463. [PMID: 36103359 DOI: 10.1227/ons.0000000000000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Malignant lesions involving the C2 vertebral body (axis) may be challenging to treat, and not all patients with cancer are good candidates for posterior cervical or occipitocervical instrumentation. OBJECTIVE To describe a modified technique of the direct anterolateral C2 kyphoplasty using a steerable osteotome, commonly used for the treatment of thoracolumbar spinal lesions. We also report a case series of 11 patients treated with this technique at our institution. METHODS The authors performed a retrospective review of all patients who underwent a C2 kyphoplasty using the anterior midline approach from 2010 to 2020. Patient demographics, tumor characteristics, pain severity (visual analog scale), Karnofsky performance status , perioperative complications, and postoperative spinal stability were assessed. RESULTS The main indication for a C2 kyphoplasty was refractory neck pain. All patients tolerated the procedure well. There were no intraoperative complications. One patient developed transient dysphagia. Visual analog scale scores were 9.00 ± 1.10 preoperative and 3.73 ± 1.85 at 2 weeks and 1.67 ± 1.66 at 3 months after the procedure and continued to stay low during the remainder of the follow-up (4-60 months). The Karnofsky performance status improved from 72.73 ± 11.04 preoperatively to 82.22 ± 8.33 at 2 weeks and 86.67 ± 5.00 at 3 months after the procedure. There was no evidence of new occurrence or progression of C2 fractures. CONCLUSION The anterior kyphoplasty using a steerable osteotome for tumors of the axis can result in lasting pain reduction and improved cervical stability while demonstrating a low complication rate.
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Affiliation(s)
- Paul R Krafft
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Ivo Peto
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Gabriel Flores-Milan
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Corey Reeves
- Department of Physical Medicine and Rehabilitation, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Sierra Klein
- Morsani College of Medicine, University of South Florida Health, Tampa, Florida, USA
| | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Nam D Tran
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA.,Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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Zakko P, Kasir R, Chen NW, Park D. Dysphagia Weakly Correlates With Other Patient-Reported Outcomes After Anterior Cervical Discectomy and Fusion. Cureus 2021; 13:e20742. [PMID: 35111434 PMCID: PMC8792121 DOI: 10.7759/cureus.20742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Dysphagia is a common complication after anterior cervical discectomy and fusion (ACDF), but it is not a routinely asked question in legacy patient-reported outcome measures (PROMs). This study analyzes whether there are associations between dysphagia and legacy outcome measures. Methods We retrospectively reviewed 168 patients who underwent ACDF surgery from 2017 to 2019 at a single institution. Demographics, anthropometric data, Neck Disability Index (NDI), Visual Analog Scale (VAS)-Arm and VAS-Neck Pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical and PROMIS-Mental scores, Charlson Comorbidity Index (CCI), and Eating Assessment Tool-10 (EAT-10) were obtained for each patient preoperatively and at one, three, six, and 12 months postoperatively. Pearson’s correlation coefficients were used to evaluate the bivariate correlations between legacy, PROMIS, and EAT-10 measures. Results Significant but weak correlations existed between NDI and EAT-10 at one, three, and six months postoperatively (correlation coefficient (R) = 0.31, 0.42, and 0.34 at one, three, and six months, p < 0.001) and VAS-Neck Pain and EAT-10 scores at one, three, and six months postoperatively (R = 0.27, 0.30, and 0.28 at one, three, and six months, p ≤ 0.004). Both PROMIS-Physical and PROMIS-Mental scores showed significant but weak correlations with EAT-10 scores at three and six months postoperatively (R = -0.29 and -0.25, p ≤ 0.01, at three months and R = -0.25 and -0.28, p < 0.01, at six months). In all comparisons of EAT-10 scores with legacy outcome measures, the significance of correlations disappeared by 12 months postoperatively. In addition, there was a positive association between CCI and EAT-10 score (β = 0.37, p < 0.05). Conclusion Weak correlations exist between self-reported dysphagia scores and legacy patient-reported outcome measures in patients undergoing ACDF. The correlation strength decreases over time; therefore, dysphagia scores should be reported separately when looking at outcomes after ACDF. Patients with more comorbidities are also at increased risk for dysphagia.
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Wang XZ, Liu H, Li JQ, Sun Y, Zhang F, Guo L, Zhang P, Dou CH, Zhang W. Comparison of Anterior Cervical Discectomy and Fusion with Cervical Laminectomy and Fusion in the Treatment of 4-Level Cervical Spondylotic Myelopathy. Orthop Surg 2021; 14:229-237. [PMID: 34904370 PMCID: PMC8867437 DOI: 10.1111/os.13058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To assess and compare the therapeutic effects of Anterior Cervical Discectomy and Fusion (ACDF) and Cervical Laminectomy and Fusion (CLF) in the treatment of 4‐level cervical. Methods We performed a retrospective review on 39 patients with 4‐level CSM who underwent ACDF or CLF in the Third Hospital of Hebei Medical University from January 2010 to December 2018. The patients were divided into ACDF group and CLF group according to the treatment. The operative index was evaluated based on intraoperative blood loss and operation time. The functional outcomes including Japanese Orthopedic Association (JOA) score and visual analogue scale (VAS) of axial pain were compared. The Cobb angle, Cobb angle improvement rate, range of motion (ROM) and ROM loss ratio were measured for radiographic evaluation. Results No major complications or deaths occurred. The average age at baseline was 55 years. There was no significant difference between the ACDF and CLF group in follow‐up time (26.29 months, 25.39 months, P > 0.05). The intraoperative blood loss was higher in the CLF group than in the ACDF group (692.67 ± 38.68 vs 392.14 ± 128.06, P < 0.05). The operation time was longer in the CLF group than in the ACDF group (206.60 ± 49.37 vs 172.64 ± 31.96, P < 0.05). Significant improvements in the VAS and JOA scores were observed in both groups (P < 0.05). No significant difference in VAS was found between the ACDF and CLF groups (P < 0.05). There was a significantly larger improvement rate of JOA score in the ACDF group than in the CLF group (60.9% ± 9.57% vs 31.5% ± 15.70%, P < 0.05). There were two (9.6%) cases with complications In the ACDF group, including one (4.8%) case of dysphagia and one (4.8%) case of pharyngodynia. In the CLF group, two patients (11.1%) developed C5 palsy. No significant difference in the incidence of complications, ROM loss ratio and Cobb angle improvement rate was found between group ACDF and group CLF (all P < 0.05). Conclusion Both ACDF and CLF were effective in the treatment of multi‐level cervical spondylosis and ACDF is more suitable for patients with 4‐level CSM.
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Affiliation(s)
- Xian-Zheng Wang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Huanan Liu
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jia-Qi Li
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yapeng Sun
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Fei Zhang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lei Guo
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Peng Zhang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chen-Hao Dou
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Zhang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
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Huang WC, Tan ECH, Huang SS, Chou CJ, Chang WK, Chu YC. Postoperative Sore Throat Helps Predict Swallowing Disturbance on Postoperative Day 30 of Anterior Cervical Spine Surgery: A Secondary Exploratory Analysis of a Randomized Clinical Trial of Tracheal Intubation Modes. Dysphagia 2021; 37:37-47. [PMID: 33620562 DOI: 10.1007/s00455-021-10247-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 01/13/2021] [Indexed: 11/25/2022]
Abstract
Nasotracheal intubation benefits dysphonia recovery after anterior cervical spine surgery (ACSS). The aim of the present study was to investigate the effect of tracheal intubation modes on post-ACSS swallowing function and identify factors associated with deglutition on postoperative day 30 (POD 30). Adult patients were randomized to receive either nasotracheal or orotracheal intubation during surgery. A numerical rating scale (NRS) was used to assess postoperative sore throat, and the Bazaz grading system was used to assess the severity of swallowing disturbance. The primary endpoints were the effect of tracheal intubation modes on postoperative sore throat and deglutition. Thereafter, we further elucidated the predictors of swallowing disturbance on POD 30. Postoperative sore throat and swallowing disturbance did not differ between the nasotracheal and orotracheal intubation groups. A secondary dataset analysis revealed that among 108 patients with complete follow-up until POD 30, 71 (65.7%) presented complete recovery without swallowing disturbance, whereas 37 (34.3%) presented varying degrees of swallowing disturbance. Receiver operating characteristic curve analysis indicated that the NRS score for sore throat predicted a swallowing disturbance-free status on POD 30. The optimal cutoff values were ≤ 4 and ≤ 2 on PODs 1 and 2, respectively. The adjusted odds ratio (OR) for independent predictors was a sore throat NRS score of ≤ 4 on POD 1 (OR 3.2; 95% CI 1.29-7.89; P = 0.012) and score of ≤ 2 on POD 2 (OR 6.67; 95% CI 2.41-18.47; P < 0.001). Therefore, tracheal intubation mode did not affect the incidence of post-ACSS swallowing disturbance, and the severity of sore throat on PODs 1 and 2 could predict a swallowing disturbance-free status on POD 30.The trial was registered at clinicaltrials.gov (Trial No. NCT03240042, date of registration 10/17/2017).
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Affiliation(s)
- Wen-Cheng Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, and Institute of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Elise Chia-Hui Tan
- National Research Institute of Chinese Medicine, Ministry of Health and Welfare, and Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Shiang-Suo Huang
- Department of Pharmacology and Institute of Medicine, Chung Shan Medical University, and Department of Pharmacy, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chi-Jen Chou
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, and Institute of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Kuei Chang
- Department of Anesthesiology, Taipei Veterans General Hospital and Institute of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ya-Chun Chu
- Department of Anesthesiology, Taipei Veterans General Hospital and Institute of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Levy AD, Carucci LR, Bartel TB, Cash BD, Chang KJ, Feig BW, Fowler KJ, Garcia EM, Kambadakone AR, Lambert DL, Marin D, Moreno C, Peterson CM, Scheirey CD, Smith MP, Weinstein S, Kim DH. ACR Appropriateness Criteria ® Dysphagia. J Am Coll Radiol 2020; 16:S104-S115. [PMID: 31054737 DOI: 10.1016/j.jacr.2019.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 12/18/2022]
Abstract
This review summarizes the relevant literature for the initial imaging of patients with symptoms of dysphagia. For patients with oropharyngeal dysphagia who have an underlying attributable cause, a modified barium swallow is usually appropriate for initial imaging but for those who have unexplained dysphagia a fluoroscopic biphasic esophagram is usually appropriate. Fluoroscopic biphasic esophagram is usually appropriate for initial imaging in both immunocompetent and immunocompromised patients who have retrosternal dysphagia. For postoperative patients with dysphagia, fluoroscopic single-contrast esophagram and CT neck and chest with intravenous (IV) contrast are usually appropriate for oropharyngeal or retrosternal dysphagia occurring in the early postoperative period where water-soluble contrast is usually preferred rather than barium sulfate. In the later postoperative period (greater than 1 month), CT neck and chest with IV contrast and fluoroscopic single-contrast esophagram are usually appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia.
| | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | | | - Brooks D Cash
- University of Texas McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | | | - Barry W Feig
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | | | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | | | - Drew L Lambert
- University of Virginia Health System, Charlottesville, Virginia
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Martin P Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
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11
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Alizadeh R, Aghsaeifard Z, Marzbanrad Z, Marzban‐Rad S. An unusual displacement of the cervical plate to the inner surface of the hypopharynx. Clin Case Rep 2020; 8:999-1001. [PMID: 32577251 PMCID: PMC7303864 DOI: 10.1002/ccr3.2790] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 01/24/2020] [Accepted: 02/11/2020] [Indexed: 11/09/2022] Open
Abstract
Unlocking and penetration of the screws and displacement or breakage of the plates are some commonly reported complications associated with the cervical implants. It is imperative to provide immediate surgical intervention along with a complete workup. Timely diagnosis and management can reduce further complications and morbidities.
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Affiliation(s)
- Reza Alizadeh
- Department of Anesthesiology and Intensive CareFaculty of MedicineAJA University of Medical SciencesTehranIran
| | - Ziba Aghsaeifard
- Department of Internal MedicineSchool of MedicineSina HospitalTehran University of Medical SciencesTehranIran
- Urology Research CenterTehran University of Medical SciencesTehranIran
| | - Zahra Marzbanrad
- Department of SurgeryFaculty of MedicineAJA University of Medical SciencesTehranIran
| | - Saeid Marzban‐Rad
- Department of SurgeryFaculty of MedicineAJA University of Medical SciencesTehranIran
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12
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Risk Factors and Assessment Using an Endoscopic Scoring System for Early and Persistent Dysphagia After Anterior Cervical Decompression and Fusion Surgery. Clin Spine Surg 2020; 33:E168-E173. [PMID: 32011353 DOI: 10.1097/bsd.0000000000000945] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
STUDY DESIGN Prospective study. OBJECTIVES Preoperative and postoperative dysphagia was evaluated by an otolaryngology doctor and a speech-language-hearing therapist using the eating assessment tool (EAT-10) and Hyodo-Komagane scores. The objective was to achieve a more precise evaluation of the incidence and risk factors of early and persistent dysphagia after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Although numerous reports have explored the risk factors for dysphagia after ACDF, these factors remain controversial. The main reason for this situation is that the methods for evaluating dysphagia are not adequate or uniform. MATERIALS AND METHODS This study involved a retrospective 47 consecutive patients who had undergone ACDF and been followed up for at least 1 year. Sagittal alignment of the cervical spine was evaluated by a preoperative x-ray. Univariate and multivariate logistic regression analyses were performed to determine risk factors for transient or persistent dysphagia. RESULTS The study showed that 34% of patients developed dysphagia in the early postoperative period and that 25.5% of patients still had persistent dysphagia 1 year postoperatively. 8.5% of patients had already developed dysphagia preoperatively, with a significant positive correlation observed between preoperative and postoperative dysphagia.Aging and smoking were significant risk factors for transient dysphagia. A preoperative cervical kyphotic angle at the C3/C4, C4/C5 disk-level and change in the kyphotic angle at C4/C5 during surgery were significant risk factors of persistent dysphagia 1 year after surgery. CONCLUSIONS This is the first study to show dysphagia after anterior cervical spine surgery using the EAT-10 score and Hyodo-Komagane score with endoscopic evaluation. Aging and smoking were significant risk factors for transient dysphagia, while preoperative local kyphosis angles of C3-C4 and C4-C5 and change in the kyphotic angle at C4/C5 during surgery may be a key alignment of risk factors for postoperative persistent dysphagia. LEVEL OF EVIDENCE Level: III.
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13
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Gutierrez S, Iwanaga J, Pekala P, Yilmaz E, Clifton WE, Dumont AS, Tubbs RS. The pharyngeal plexus: an anatomical review for better understanding postoperative dysphagia. Neurosurg Rev 2020; 44:763-772. [PMID: 32318923 DOI: 10.1007/s10143-020-01303-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 01/22/2023]
Abstract
The pharyngeal plexus is an essential anatomical structure, but the contributions from the glossopharyngeal and vagus nerves and the superior cervical ganglion that give rise to the pharyngeal plexus are not fully understood. The pharyngeal plexus is likely to be encountered during various anterior cervical surgical procedures of the neck such as anterior cervical discectomy and fusion. Therefore, a detailed understanding of its anatomy is essential for the surgeon who operates in and around this region. Although the pharyngeal plexus is an anatomical structure that is widely mentioned in literature and anatomy books, detailed descriptions of its structural nuances are scarce; therefore, we provide a comprehensive review that encompasses all the available data from this critical structure. We conducted a narrative review of the current literature using databases like PubMed, Embase, Ovid, and Cochrane. Information was gathered regarding the pharyngeal plexus to improve our understanding of its anatomy to elucidate its involvement in postoperative spine surgery complications such as dysphagia. The neural contributions of the cranial nerves IX, X, and superior sympathetic ganglion intertwine to form the pharyngeal plexus that can be injured during ACDF procedures. Factors like surgical retraction time, postoperative hematoma, surgical hardware materials, and profiles and smoking are related to postoperative dysphagia onset. Thorough anatomical knowledge and lateral approaches to ACDF are the best preventing measures.
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Affiliation(s)
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA.
| | | | - Emre Yilmaz
- Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | | | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA.,Department of Anatomical Sciences, St. George's University, St. George's, West Indies, Grenada.,Department of Neurosurgery, Ochsner Health System, Ochsner Neuroscience Institute, New Orleans, LA, USA.,Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
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14
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Yee TJ, Swong K, Park P. Complications of anterior cervical spine surgery: a systematic review of the literature. JOURNAL OF SPINE SURGERY 2020; 6:302-322. [PMID: 32309668 DOI: 10.21037/jss.2020.01.14] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The anterior approach to the cervical spine is commonly utilized for a variety of degenerative, traumatic, neoplastic, and infectious indications. While many potential complications overlap with those of the posterior approach, the distinct anatomy of the anterior neck also presents a unique set of hazards. We performed a systematic review of the literature to assess the etiology, presentation, natural history, and management of these complications. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a PubMed search was conducted to evaluate clinical studies and case reports of patients who suffered a complication of anterior cervical spine surgery. The search specifically included articles concerning adult human subjects, written in the English language, and published from 1989 to 2019. The PubMed search yielded 240 articles meeting our criteria. The overall rates of complications were as follows: dysphagia 5.3%, esophageal perforation 0.2%, recurrent laryngeal nerve palsy 1.3%, infection 1.2%, adjacent segment disease 8.1%, pseudarthrosis 2.0%, graft or hardware failure 2.1%, cerebrospinal fluid leak 0.5%, hematoma 1.0%, Horner syndrome 0.4%, C5 palsy 3.0%, vertebral artery injury 0.4%, and new or worsening neurological deficit 0.5%. Morbidity rates in anterior cervical spine surgery are low. Nevertheless, the unique anatomy of the anterior neck presents a wide variety of potential complications involving vascular, aerodigestive, neural, and osseous structures.
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Affiliation(s)
- Timothy J Yee
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Kevin Swong
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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15
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Iyer S, Kim HJ, Bao H, Smith JS, Protopsaltis TS, Mundis GM, Passias P, Neuman BJ, Klineberg EO, Lafage V, Ames CP. Cervical Deformity Patients Have Baseline Swallowing Dysfunction but Surgery Does Not Increase Dysphagia at 3 Months: Results From a Prospective Cohort Study. Global Spine J 2019; 9:532-539. [PMID: 31431877 PMCID: PMC6686378 DOI: 10.1177/2192568218807132] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES Most studies of dysphagia in the cervical spine have focused on a degenerative patient population; the rate of dysphagia following surgery for cervical deformity (CD) is unknown. This study aims to investigate if surgery for cervical deformity results in postoperative dysphagia. METHODS Patients with CD undergoing surgery from 2013 to 2015 were prospectively enrolled to evaluate dysphagia. Demographic, operative, and radiographic variables were analyzed. The Quality of Life in Swallowing Disorders (SWAL-QoL) was used to measure dysphagia. Paired t test, independent t tests, and bivariate Pearson correlations were performed. RESULTS A total of 88 CD patients, aged 61.52 ± 10.52 years, were enrolled. All patients (100%) had 3-month SWAL-QoL for analysis. The baseline preoperative SWAL-QoL was 78.35. This is roughly the same level of dysphagia as an anterior cervical discectomy patient that is 3 weeks removed from surgery. Increasing body mass index (BMI) was correlated with decreased SWAL-QoL score (r = -0.30, P = .001). Age, gender, smoking, and Charlson Comorbidity Index (CCI) showed no significant correlations with preoperative SWAL-QoL. Patients with prior cervical surgery had a lower preoperative SWAL-QoL (P = .04). While 11 patients had acute postoperative dysphagia, CD surgery did not result in lower SWAL-QoL at 3 months (77.26 vs 78.35, P = .53). Surgical variables, including estimated blood loss (EBL), anterior or posterior fusion levels, steroid use, preoperative traction, staged surgery, surgical approach, anterior corpectomy, posterior osteotomy, and UIV (upper instrumented vertebrae) location, showed no impact on postoperative SWAL-QoL. Correction of cervical kyphosis was not correlated to 3-month SWAL-QoL scores or the change in SWAL-QoL scores. CONCLUSIONS While patients undergoing surgery for cervical deformity had swallowing dysfunction at baseline, we did not observe a significant decline in SWAL-QoL scores at 3 months. Patients with prior cervical surgery and higher BMI had a lower baseline SWAL-QoL. There were no surgical or radiographic variables correlated to a change in SWAL-QOL score.
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Affiliation(s)
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA,Han Jo Kim, Hospital for Special Surgery, New York NY 10021, USA.
| | - Hongda Bao
- Hospital for Special Surgery, New York, NY, USA
| | - Justin S. Smith
- University of Virginia Health System, Charlottesville, VA, USA
| | | | | | - Peter Passias
- New York University Center for Musculoskeletal Care, New York, NY, USA
| | - Brian J. Neuman
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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16
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Fisahn C, Yilmaz E, Iwanaga J, Schmidt C, Benca E, Chapman JR, Oskouian RJ, Tubbs RS. Avoiding the Esophageal Branches of the Recurrent Laryngeal Nerve During Retractor Placement: Precluding Postoperative Dysphagia During Anterior Approaches to the Cervical Spine. Global Spine J 2019; 9:383-387. [PMID: 31218195 PMCID: PMC6562208 DOI: 10.1177/2192568218810198] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Anatomical cadaver study. OBJECTIVES Postoperative dysphagia is a significant complication following anterior approaches to the cervical spine and the etiology of this complication is poorly understood. Herein, we studied the esophageal branches of the recurrent laryngeal nerves to improve understanding of their anatomy and potential involvement in dysphagia. METHODS Ten fresh frozen cadaveric human specimens were dissected (20 sides). All specimens were adults with no evidence of prior surgery of the anterior neck. The recurrent laryngeal nerves were identified under a surgical microscope and observations and measurements of their esophageal branches made. RESULTS For each recurrent laryngeal nerve, 5-7 (mean 6.2) esophageal branches were identified. These branches ranged from 0.8 to 2.1 cm (mean 1.5 cm) in length and 0.5 to 2 mm (mean 1 mm) in diameter. They arose from the recurrent laryngeal nerves between vertebral levels T1 and C6. They all traveled to the anterior aspect of the esophagus. No statistical differences were seen between left and right sides or between sexes. CONCLUSION The esophageal branches of the recurrent laryngeal nerve have been poorly described and could contribute to complications such as swallowing dysfunction following anterior cervical discectomy and fusion procedures. Therefore, a better understanding of their anatomy is important for spine surgeons. Our study revealed that these branches are always present on both sides and the anterior surface of the esophagus should be avoided while retracting it in order to minimize the risk of postoperative dysphagia.
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Affiliation(s)
- Christian Fisahn
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
- Seattle Science Foundation, Seattle, WA, USA
- BG University Hospital Bergmannsheil, Ruhr University Bochum, Germany
| | - Emre Yilmaz
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
- Seattle Science Foundation, Seattle, WA, USA
- BG University Hospital Bergmannsheil, Ruhr University Bochum, Germany
- Emre Yilmaz, Swedish Neuroscience Institute, Swedish
Medical Center, 550 17th Avenue, Seattle, WA 98122, USA.
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, WA, USA
| | - Cameron Schmidt
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Eric Benca
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Jens R. Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
| | - Rod J. Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA,
USA
| | - R. Shane Tubbs
- Seattle Science Foundation, Seattle, WA, USA
- St George’s University, Grenada
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17
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Dysphagia Caused by Cervical Plate Erosion through the Hypopharynx. ACG Case Rep J 2019; 5:e104. [PMID: 30643847 PMCID: PMC6317835 DOI: 10.14309/crj.2018.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 11/12/2018] [Indexed: 12/30/2022] Open
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18
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Liu J, Zhang Y, Hai Y, Kang N, Han B. Intravenous and local steroid use in the management of dysphagia after anterior cervical spine surgery: a systematic review of prospective randomized controlled trails (RCTs). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:308-316. [DOI: 10.1007/s00586-018-5840-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 09/04/2018] [Accepted: 11/25/2018] [Indexed: 12/13/2022]
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Abstract
Barium upper GI series performed by an interested and competent radiologist is still a very useful study to evaluate a variety of esophagogastric disorders. It usually provides information complementary to upper endoscopy and other foregut studies. Barium upper GI series is an important part of the diagnostic workup for gastroesophageal reflux disease, hiatal hernia, and esophageal motility disorders including achalasia. It is also an important part of the follow-up after operation for these common problems and after other operations such as resection or bariatric surgery. The GI radiologist should be an important member of the foregut surgery team.
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Influence of Postoperative O-C2 Angle on the Development of Dysphagia After Occipitocervical Fusion Surgery: Results from a Retrospective Analysis and Prospective Validation. World Neurosurg 2018; 116:e595-e601. [PMID: 29777893 DOI: 10.1016/j.wneu.2018.05.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/06/2018] [Accepted: 05/08/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Postoperative dysphagia is a known complication of anterior cervical surgery, but its incidence and possible mechanisms are seldom reported after occipitocervical fusion (OCF). Our objective was to study the relationship between craniocervical alignment and the development of dysphagia after OCF for the treatment of basilar invagination with atlantoaxial instability. METHODS The study consisted of a retrospective series and a prospective series. Seventy-eight patients who underwent OCF (30 male, 48 female) were reviewed in the retrospective series. The presence and duration of postoperative dysphagia were recorded with an in-person questionnaire or telephone interview. Sagittal reconstructed computed tomography images before and after the procedure were collected. The O-C2 angle and C2-C7 angle were measured. The relationship of these parameters and their influence to the incidence of dysphagia were analyzed. The patients were grouped according to whether they developed postoperative dysphagia (group A) or not (group B). A prospective case series of 27 patients (group C) were reported to verify the influence of O-C2 angle on postoperative dysphagia. RESULTS In the retrospective case series, 19 patients (24.4%) complained of postoperative dysphagia after OCF. The change in the O-C2 angle was significantly lower in group A than in group B (P < 0.001). In the prospective case series, only 1 patient (3.7%) complained of postoperative dysphagia. CONCLUSIONS O-C2 angle plays an important role in the development of postoperative dysphagia after OCF procedure. Careful intraoperative alignment of the O-C2 angle may help to reduce the incidence and severity of postoperative dysphagia after OCF.
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Lemaire E, Ciftci S, Debry C. Dysphagia 27 years after cervical disc arthroplasty. Eur Ann Otorhinolaryngol Head Neck Dis 2018; 135:287-289. [PMID: 29706590 DOI: 10.1016/j.anorl.2018.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Dysphagia is a frequent postoperative symptom after anterior cervical disc arthroplasty. However, onset of dysphagia and neck pain a long time after surgery should suggest a diagnosis of prosthesis dislocation. CARE REPORT A 65-year-old man with a history of cervical disc arthroplasty 27 years previously consulted for rapidly progressive dysphagia with no other associated symptoms. Physical examination and CT scan confirmed the diagnosis of anterior dislocation of the prosthesis with no signs of perforation. Surgical extraction via a neck incision allowed resolution of the symptoms. DISCUSSION Prosthesis dislocation should be considered in a patient with a history of cervical disc arthroplasty presenting with dysphagia and neck pain. The clinical and radiological assessment confirmed the diagnosis and early surgical management allowed resolution of the symptoms and avoided complications such as pharyngo-oesophageal perforation.
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Affiliation(s)
- E Lemaire
- Service ORL, CHU de Hautepierre, avenue Molière, 67098 Strasbourg cedex, France.
| | - S Ciftci
- Service ORL, CHU de Hautepierre, avenue Molière, 67098 Strasbourg cedex, France
| | - C Debry
- Service ORL, CHU de Hautepierre, avenue Molière, 67098 Strasbourg cedex, France
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23
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Dysphagia Caused by Cervical Plate Erosion through the Hypopharynx. ACG Case Rep J 2018. [DOI: 10.14309/02075970-201805120-00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Kim JY, Hong JT, Oh JS, Jain A, Kim IS, Lim SH, Kim JS. Influence of neck postural changes on cervical spine motion and angle during swallowing. Medicine (Baltimore) 2017; 96:e8566. [PMID: 29137075 PMCID: PMC5690768 DOI: 10.1097/md.0000000000008566] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Occipitocervical (OC) fixation in a neck retraction position could be dangerous due to the risk of postoperative dysphagia. No previous study has demonstrated an association between the cervical posture change and cervical spine motion/angle during swallowing. So, we aimed to analyze the influence of neck posture on the cervical spine motion and angle change during swallowing.Thirty-seven asymptomatic volunteers were recruited for participation this study. A videoflurographic swallowing study was performed in the neutral and retracted neck posture. We analyzed the images of the oral and pharyngeal phases of swallowing and compared the angle and the position changes of each cervical segment.In the neutral posture, C1 and C2 were flexed, while C5, C6, and C7 were extended. C3, C4, C5, C6, and C7 moved posteriorly. All cervical levels, except for C5, moved superiorly. In the retraction posture, C0 and C1 were flexed, while C6 was extended during swallowing. All cervical levels moved posteriorly. C1, C2, C3, and C4 moved superiorly. The comparison between 2 postures shows that angle change is significantly different between C0, C2, and C5. Posterior translation change is significantly different in the upper cervical spine (C0, C1, and C2) and C7. Superior movement is significantly different in C0.C0 segment is most significantly different between neutral and retraction posture in terms of angle and position change. These data suggest that C0 segment could be a critical level of compensation that allows swallowing even in the retraction neck posture regarding motion and angle change. So, it is important not to do OC fixation in retraction posture. Also, sparing C0 segment could provide some degree of freedom for the compensatory movement and angle change to avoid dysphagia after OC fixation.
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Affiliation(s)
- Jun Young Kim
- Department of Neurosurgery, Wiltse Memorial Hospital
| | | | - Joo Seon Oh
- Department of Rehabilitation, Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | | | | | - Seong Hoon Lim
- Department of Rehabilitation, Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Jun Sung Kim
- Department of Rehabilitation, Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
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Risk factors and preventative measures of early and persistent dysphagia after anterior cervical spine surgery: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1209-1218. [PMID: 28988275 DOI: 10.1007/s00586-017-5311-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 08/31/2017] [Accepted: 09/23/2017] [Indexed: 12/24/2022]
Abstract
PURPOSE To conduct a systematic review of literature to determine risk factors and preventative measures of early and persistent dysphagia after anterior cervical spine surgery (ACSS). METHODS On March 2017, we searched the database PubMed, Medline, EMBASE, the Cochrane library, Clinical key, Springer link and Wiley Online Library without time restriction using the term 'dysphagia', 'swallowing disorders', and 'anterior cervical spine surgery'. Selected papers were examined for the level of evidence by published guidelines as level I, level II, level III, level IV studies. We investigated risk factors and preventative measures of early or persistent dysphagia after ACSS from these papers. RESULTS The initial search yielded 515 citations. Fifty-nine of these studies met the inclusion and exclusion criteria. Three of them were level I evidence studies, 29 were level II evidence studies, 22 were level III evidence studies, and 3 were level IV evidence studies. Preventable risk factors included prolonged operative time, use of rhBMP, endotracheal tube cuff pressure, cervical plate type and position, dC2-C7 angle, psychiatric factors, tobacco usage, prevertebral soft tissue swelling, SLN or RLN palsy or injury of branches. Preventative measures included preoperative tracheal traction exercise, maintaining endotracheal tube cuff pressure at 20 mm Hg, avoiding routine use of rhBMP-2, use of zero-profile implant, use of Zephir plate, use of new cervical retractor, steroid application, avoiding prolonged operating time, avoiding overenlargement of cervical lordosis, decreasing surgical levels, ensuring knowledge of anatomy of superior laryngeal nerve and recurrent laryngeal nerve, to comfort always, patients quitting smoking and doctors ensuring improved skills. Unpreventable risk factors included age, gender, multilevel surgery, revision surgery, duration of preexisting pain, BMI, blood loss, upper levels, preoperative comorbidities and surgical type. CONCLUSION Adequate preoperative preparation of the patients including preoperative tracheal traction exercise and quitting smoking, proper preventative measures during surgery including maintaining endotracheal tube cuff pressure at 20 mm Hg, avoiding routine use of rhBMP-2, use of zero-profile implant, use of Zephir plate, use of new cervical retractor, steroid application, avoiding prolonged operating time, avoiding overenlargement of cervical lordosis and decreasing surgical levels, doctors ensuring knowledge of anatomy, improved surgical techniques and to comfort always are essential for preventing early and persistent dysphagia after ACSS.
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Kim SW, Jang C, Yang MH, Lee S, Yoo JH, Kwak YH, Hwang JH. The natural course of prevertebral soft tissue swelling after anterior cervical spine surgery: how long will it last? Spine J 2017; 17:1297-1309. [PMID: 28495241 DOI: 10.1016/j.spinee.2017.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 04/22/2017] [Accepted: 05/02/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Prevertebral soft tissue swelling (PSTS) after anterior cervical spine surgery (ACSS) has been regarded as one of the critical complications that cause airway obstruction. Still, however, no research has dealt with how PSTS returns to presurgery status after ACSS; most recommendations are being performed without information about its natural course, focusing on acute-phase swelling after surgery. PURPOSE The study aimed to examine how long postsurgery PSTS lasts and when it returns to its presurgery state, and to analyze the actual influence of a number of factors to observe the natural progress of postsurgery PSTS. STUDY DESIGN/SETTING This is a prospective observational study. PATIENT SAMPLE The sample included a total of 160 patients who underwent ACSS, including anterior cervical discectomy and fusion (ACDF) and cervical total disc replacement (TDR). OUTCOME MEASURES The diameter of PSTS measured at each set time point after surgeries was compared with PSTS measurements before surgery, and analyzed with factors influencing PSTS. METHODS Anterior and posterior diameters of the anterior soft tissue of C3 (pharyngeal airway) and C6 (laryngeal airway) were measured using simple lateral radiography before surgery, immediately after surgery, at 2 weeks, 1, 3, 6, and 12 months after surgery. The progress of postsurgery PSTS was analyzed according to patients' individual characteristics, such as age, gender, weight, body mass index (BMI), smoking status, use of antiplatelet therapy, hypertension and diabetes mellitus, complaints of dysphagia, along with surgical factors such as anesthesia time, operation time, numbers of involved operation segments, transfusion, estimated blood loss , and operation method. Multivariable analysis by generalized linear mixed model was used to perform additional univariable analysis on variables found to be related to PSTS. In addition, to find the postsurgery interval at which PSTS naturally stabilizes, repeated measures analysis of variance and Bonferroni method were used to perform post-hoc tests. There were no sources of funding and no conflicts of interest associated with this study. RESULTS For ACDF, the mean values (95% confidence interval [CI]) of PSTS in C3 were 4.38 (4.04~4.71), 10.40 (9.64~11.17), 7.72 (7.10~8.35), 6.24 (5.74~6.69), 5.43 (5.03~5.82), 5.14 (4.77~5.50), and 4.96 (4.59~5.33) mm at each follow-up time, respectively. In C6, the average values (95% CI) of PSTS were 14.43 (13.96~14.91), 19.18 (18.59~19.77), 17.92 (17.37~18.47), 16.98 (16.45~17.51), 16.18 (15.67~16.69), 15.95 (15.50~16.40), and 15.49 (15.50~16.40) mm. For cervical TDR, the mean values (95% CI) of PSTS in C3 were 3.67 (3.45~3.89), 8.05 (7.17~8.93), 5.42 (4.92~5.91), 4.57 (4.21~4.92), 4.12 (3.99~4.36), 4.10 (3.87~4.34), and 3.90 (3.66~4.14) mm at each follow-up time, respectively. In C6, the average values (95% CI) of PSTS were 13.61 (12.96~14.25), 16.51 (15.80~17.21), 15.77 (15.13~16.42), 15.24 (14.61~15.87), 14.62 (14.01~15.22), 14.52 (13.88~15.17), and 13.94 (13.20~14.68) mm. It is discovered that PSTS after surgery returned to presurgery status within 1 to 3 months in the pharyngeal airway (C3) and within 3 to 6 months in the laryngeal airway (C6), and gender, BMI, and surgery method (ACDF) were determined to be the factors having influence on PSTS after surgery. CONCLUSIONS It is necessary to pay attention to PSTS and patient conditions after ACSS for at least 1 to 6 months postsurgery, depending on surgical method and operation levels.
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Affiliation(s)
- Seok Woo Kim
- Spine Center, Hallym University Sacred Heart Hospital, 896 Pyeongchon-dong, Dongan-gu, Anyang-si, Gyeonggi-do 431-070, Republic of Korea; Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, 896 Pyeongchon-dong, Dongan-gu, Anyang-si, Gyeonggi-do 431-070, Republic of Korea.
| | - Chulyoung Jang
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, 896 Pyeongchon-dong, Dongan-gu, Anyang-si, Gyeonggi-do 431-070, Republic of Korea
| | - Myung Ho Yang
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, 896 Pyeongchon-dong, Dongan-gu, Anyang-si, Gyeonggi-do 431-070, Republic of Korea
| | - Seonjong Lee
- Spine Center, Hallym University Sacred Heart Hospital, 896 Pyeongchon-dong, Dongan-gu, Anyang-si, Gyeonggi-do 431-070, Republic of Korea; Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, 896 Pyeongchon-dong, Dongan-gu, Anyang-si, Gyeonggi-do 431-070, Republic of Korea
| | - Je Hyun Yoo
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, 896 Pyeongchon-dong, Dongan-gu, Anyang-si, Gyeonggi-do 431-070, Republic of Korea
| | - Yoon Hae Kwak
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, 896 Pyeongchon-dong, Dongan-gu, Anyang-si, Gyeonggi-do 431-070, Republic of Korea
| | - Ji Hyo Hwang
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, 1, Singil-ro, Yeongdeungpo-gu, Seoul 150-950, Republic of Korea
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Outpatient Anterior Cervical Discectomy and Fusion is Associated With Fewer Short-term Complications in One- and Two-level Cases: A Propensity-adjusted Analysis. Spine (Phila Pa 1976) 2017; 42:1044-1049. [PMID: 28697092 DOI: 10.1097/brs.0000000000001988] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of prospectively collected data from the National Surgical Quality Improvement Program (NSQIP) database. OBJECTIVE To determine the postoperative morbidity of one- and two-level outpatient anterior cervical discectomy and fusion (ACDF) relative to inpatient cases, and risk factors for postdischarge complications. SUMMARY OF BACKGROUND DATA ACDF is increasingly performed as an outpatient procedure, with evidence demonstrating outpatient one-level ACDF to be associated with fewer postoperative complications than inpatients. The postoperative morbidity and safety of outpatient two-level ACDF as a separate cohort is not well understood. METHODS ACDF cases from NSQIP 2011 to 2014 were identified. Differences in baseline characteristics between inpatient and outpatient cases were determined, and propensity score adjustment was used to account for selection bias. One- and two-level ACDF cohorts were analyzed separately. Unadjusted and propensity-adjusted multivariable logistic regressions were performed to determine the risk of postoperative complications in outpatient cases relative to inpatient cases, and predictors of postdischarge complications. RESULTS A total of 22,006 ACDF cases were included, of which 4759 were outpatient procedures. Propensity-adjusted differences in preoperative characteristics were all P > 0.5, indicating successful adjustment of selection bias. Among 6890 two-level cases, of which 1429 (20.7%) were outpatient, the overall unadjusted rate of complications was 1.47% for outpatients and 3.94% for inpatients, P < 0.001. Propensity-adjusted multivariable regression showed a lower rate of postoperative complications in the outpatient cohort (odds ratio 0.48, 95% confidence interval 0.30-0.75). Greater comorbidity burden as measured by Charlson Comorbidity Index, higher American Society of Anesthesiologists class, chronic steroid use, hypertension, and male sex were independent risk factors for postdischarge complications. CONCLUSION After adjusting for selection bias and patient risk factors, outpatient two-level ACDF was not associated with increased postoperative morbidity relative to inpatients, and may be considered in appropriately indicated patients. LEVEL OF EVIDENCE 3.
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Yamagata T, Naito K, Yoshimura M, Ohata K, Takami T. Influence of prevertebral soft tissue swelling on dysphagia after anterior cervical discectomy and fusion using a rectangular titanium stand-alone cage. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:179-186. [PMID: 29021668 PMCID: PMC5634103 DOI: 10.4103/jcvjs.jcvjs_57_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Postoperative oropharyngeal complications such as dysphagia after anterior cervical spine surgery are some of the least discussed surgery-related complications. The purpose of this retrospective study is to investigate the incidence and possible risk factors for 30-day postoperative dysphagia after anterior cervical discectomy and fusion (ACDF). MATERIALS AND METHODS This study included 152 consecutive patients who underwent 1- or 2-level ACDF using a rectangular titanium stand-alone cage in our institutes. Surgery-related dysphagia early after surgery was analyzed based on hospital charts. Radiological evaluation of prevertebral soft tissue swelling (PSTS) was performed by comparing plain lateral radiographs of the cervical spine before surgery with those after surgery. The percentage of PSTS (%PSTS) was defined by retropharyngeal soft tissue diameter divided by vertebral diameter. Positive %PSTS was determined when %PSTS exceeded its mean + 2 standard deviations. RESULTS Twelve patients (7.9%) demonstrated prolonged symptoms of dysphagia within 30-day postoperatively. All patients eventually demonstrated satisfactory or acceptable recovery late after surgery, except one case of hypoglossal nerve palsy. %PSTS was significantly highest early after surgery and returned to presurgical levels within 30 days after surgery. Statistical analysis suggested that the positive %PSTS at C3 or C4 level early after surgery was significantly associated with the occurrence of postoperative dysphagia. CONCLUSIONS Although the possible reasons for postoperative dysphagia may not only be multifactorial but also be highly surgeon-dependent, such a complication is still underestimated and needs to be carefully resolved. %PSTS appeared to be easy and reliable index to judge the possible risk of postoperative dysphagia.
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Affiliation(s)
- Toru Yamagata
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kentaro Naito
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masaki Yoshimura
- Department of Neurosurgery, Yao Tokushukai General Hospital, Osaka, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Valenzano TJ, Waito AA, Steele CM. A Review of Dysphagia Presentation and Intervention Following Traumatic Spinal Injury: An Understudied Population. Dysphagia 2016; 31:598-609. [PMID: 27412004 PMCID: PMC5215788 DOI: 10.1007/s00455-016-9728-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 07/02/2016] [Indexed: 10/21/2022]
Abstract
Dysphagia is reported to be a common secondary complication for individuals with traumatic spinal injuries. Different etiologies of traumatic spinal injuries may lead to different profiles of swallowing impairment. We conducted a systematic review to determine the characteristics of dysphagia after traumatic spinal injury and to describe interventions currently used to improve swallowing function in this population. A comprehensive multiengine literature search identified 137 articles of which five were judged to be relevant. These underwent review for study quality, rating for level of evidence, and data extraction. The literature describing dysphagia after traumatic spinal injury was comprised predominantly of low-level evidence and single case reports. Aspiration, pharyngeal residue, and decreased/absent hyolaryngeal elevation were found to be common characteristics of dysphagia in this population. The most commonly used swallowing interventions included tube feeding, compensatory swallowing strategies, and steroids/antibiotics. Improvement in swallowing function following swallowing intervention was reported in all studies; however, there was no control for spontaneous recovery. The results demonstrate a need for high-quality research to profile the pathophysiology of dysphagia after traumatic spinal injury and controlled studies to demonstrate the efficacy of swallowing interventions in this population.
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Affiliation(s)
- Teresa J Valenzano
- Toronto Rehabilitation Institute - University Health Network, 550 University Avenue, Toronto, ON, M5G 2A2, Canada.
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, 500 University Avenue, Toronto, ON, M5G 1V7, Canada.
| | - Ashley A Waito
- Toronto Rehabilitation Institute - University Health Network, 550 University Avenue, Toronto, ON, M5G 2A2, Canada
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, 500 University Avenue, Toronto, ON, M5G 1V7, Canada
| | - Catriona M Steele
- Toronto Rehabilitation Institute - University Health Network, 550 University Avenue, Toronto, ON, M5G 2A2, Canada
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, 500 University Avenue, Toronto, ON, M5G 1V7, Canada
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Qian SJ, Ye XS, Chen WS, Li WL. Missed diagnosis of oesophageal perforation in ankylosing spondylitis cervical fracture: Two case reports and literature review. J Int Med Res 2016; 44:170-5. [PMID: 26740499 PMCID: PMC5536578 DOI: 10.1177/0300060515614230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/30/2015] [Indexed: 12/02/2022] Open
Abstract
Oesophageal perforation after blunt injury cervical fracture in patients with ankylosing spondylitis (AS) is rarely reported. The early diagnosis of oesophageal perforation is extremely important. We present two cases of patients with AS who sustained cervical fracture dislocation and spinal cord injury. The ossified sharp fragments caused oesophageal perforation, and the delayed diagnoses had serious consequences. Oesophageal perforation should be suspected in patients with AS and cervical fracture if bone fragments are pressing against the oesophagus and a gas shadow is visible around the fracture site on computed tomography imaging.
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Affiliation(s)
- Sheng-Jun Qian
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xue-Shi Ye
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei-Shan Chen
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wan-Li Li
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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